1 Predictors of Retention in Care Among HIV+ and At-Risk Youth Sion Kim Harris, PhD Cathryn L. Samples, MD, MPH Peter Keenan, RN, C-PNP Durrell J. Fox, BS Maurice W. Melchiono, RN, MS, C-FNP Elizabeth R. Woods, MD, MPH Boston HAPPENS Program Participants Children’s Hospital Boston, Harvard Medical School Society for Adolescent Medicine Annual Meeting 2002

2 Study Grant Support Special Projects of National Significance Program (SPNS) #BRH , HRSA, DHHS Leadership in Adolescent Health Project # 5T 71 MC , MCH Bureau, HRSA, DHHS W.T. Grant Foundation Children’s Hospital’s Aerosmith Fund for HIV Care and Prevention

3 Background At-risk youth are hard to engage and retain in care Ancillary services such as outreach, case management, and mental health services believed to enhance retention in care

4 Study Aims Describe retention in care of youth clients of a comprehensive adolescent HIV care program (Boston HAPPENS Program) Assess impact of outreach, case management, mental health services on likelihood of retention over time, adjusted for potential confounding factors

5 Program Description Boston HIV Adolescent Provider and Peer Education Network for Services (HAPPENS) Coordinated network of 8 agencies serving at-risk youth ages Comprehensive care including HIV CTS, outreach, nurse case management, mental health services, and medical care

6 Study Population HAPPENS clients seen during data collection period (4.5 years) Clients excluded from analysis if had no more than two standard HIV counseling and testing visits

7 Data Collection Method Standard forms used by all 10 SPNS programs “Contact” form: used at client enrollment or street/phone contact to record demographic and HIV risk info, outreach services provided “Intervention” form: used at each health visit to record health care, case management, mental health services provided

8 Data Analyses Method Survival analysis: Retention measure –Number of days between first and last visits during data collection period Censored cases –Clients with at least one visit during last program year

9 Key Predictor Variables Number of outreach contacts Categories: 0, 1, >2 times Number of mental health service visits Categories: 0, 1, >2 times Number of case management visits Categories: 0, 1-2, >3 times

10 Other Potential Predictors Age Gender Race/ethnicity HIV status Mental health system involvement Homeless/runaway Self-identified sexual orientation Ever pregnant Ever had STD Any unprotected sex Any survival sex, sex with HIV+ or injection drug using partner (high risk sex) Any substance abuse, injection drug use, or needle-sharing Client Demographic and HIV Risk Factors:

11 Type of site of initial care –Multi-service outreach agency –Community health center –Hospital Other Potential Predictors (cont’d)

12 Statistical Tests All analyses were gender-stratified Descriptive analyses: –Kaplan-Meier survival curve analysis Bivariate analyses: –Log-rank test to assess group differences in retention times

13 Statistical Tests (cont’d) Multivariate Cox Proportional Hazards (PH) regression modeling –Variables related to retention at p<0.10 entered into model, including age, HIV status –Adjusted Hazard Ratio (AHR) and 95% CI PROC SURVIVAL in SUDAAN® used to account for potential intra-cluster correlation within sites

14 Client Characteristics by Gender (Total N=1426)

15 Overall Program Retention Retention times ranged from days for males, for females About two-thirds of clients returned for at least a second visit (males=64.3%, females=70.0%) 25% in both gender groups retained for more than a year 10% of males and 15% of females retained for more than two years

16 Probability of Retention Over Time by Number of Outreach Contacts MALESFEMALES >2 contacts* ¥1¥ Number of days between first and last visits Cum Probability of Retention Log-rank test: *p<0.001; ¥ p=0.002

17 Probability of Retention Over Time by Number of Mental Health Visits MALESFEMALES Cum Probability of Retention Number of days between first and last visits >2 visits* ¥1¥ Log-rank test: *p<0.001; ¥ p=0.03

18 Probability of Retention Over Time by Case Management Visits Cum Probability of Retention Number of days between first and last visits MALES >3 visits* >3 visits* FEMALES Log-rank test: *p<0.001

19 Cox PH Modeling Results, Males * Adjusted for age, HIV status, race/ethnicity, sexual orientation, homelessness, MH-system involvement, and high risk sex behaviors

20 Cox PH Modeling Results, Females * Adjusted for age, HIV status, race/ethnicity, sexual orientation, any pregnancy, and any unprotected sex with males

21 Discussion Some hard-to-reach, at-risk youth can be retained in care, with intensive efforts Increased outreach and case management associated with  retention (adjusted for client demographic and risk factors) Mental health counseling related to  retention of male clients

22 Study Limitations HAPPENS clients may not be representative of all at-risk youth Visits to providers outside of program not included Variability in quality, completeness of data across sites Cell sizes for some variables small

23 Other client and program factors related to retention unmeasured Study Limitations (cont’d)

24 Implications Comprehensive services help retain at-risk youth in care Ancillary services such as outreach, case management, mental health services need to be more consistently funded for all at-risk youth, not just HIV+